Chapter 47 Integumentary Dysfunction
The nurse is caring for a child who has full-thickness burns encircling the chest. After using a Doppler to assess the circulation, the nurse determines that the child has impaired perfusion and loss of pulse to some extent. Which treatment procedure would help the child in this situation?
Escharotomy
Which nursing intervention is the highest priority in the initial care of a child with a major burn injury?
Establishing and maintaining the child's airway
An effective strategy to reduce the stress of burn dressing procedures is to
Give the child as many choices as possible
A toddler sustains a minor burn on the hand from hot coffee. The first action in treating this burn is to
Hold the burned area under cool running water.
Which physiologic change causes the edema formation that occurs with burns?
Increased capillary permeability
After the acute stage and during the healing process, the primary complication from burn injury is
Infection
Which should the nurse include when teaching parents about preventing childhood burn injuries
Keep hot liquids out of reach Baby-proof electrical outlets Test water temperature before placing your child in the tub bath
The family of a 4-month-old infant will be vacationing at the beach. The best recommendation to this family is to
Keep the infant in total shade at all times.
A mother calls the emergency department nurse because her child was stung by a scorpion. The nurse should recommend
Keeping the child quiet and coming to emergency department
While caring for a child with severe burn injuries, the nurse finds that the child has inadequate hydration. Which complications would the nurse expect to find in the child?
Lethargy Spiking Fever Paralytic ileus
Appropriate dressing for an open wound?
Moist dressing of the wound increases collagen synthesis and accelerates reepithelialization. Therefore, wound healing is faster when a moist dressing is used to cover an open wound. It takes 1 to 14 days for a wound to heal if a moist dressing is used.
The primary health care provider has prescribed an anesthetic drug to a child with severe burn injuries. The nurse observed that the onset of the drug occurs in 1 minute and reaches its peak at 4 minutes. Which medication should the nurse anticipate in the child's prescription?
Nitrous oxide (Inomax)
Biologic dressings are applied to a child with partial-thickness burns of both legs. Nursing actions related to this include
Observing wounds for signs of infection
What is the most important step in the management of cellulitis?
Oral or parenteral antibiotics
A 4-year-old child is admitted with major facial burns. What therapeutic measures should the nurse take?
Prioritize airway maintenance Provide fluid replacement therapy Feed the patient a diet rich in protein
The nurse is caring for a child with a hand wound. The nurse instructs the parents of the child to provide foods rich in vitamin C. Which outcome should the nurse expect from this intervention?
Promotes collagen fiber formation
Fentanyl and midazolam (Versed) are given before debridement of a child's burn wounds. These drugs are important to
Provide pain relief
A child experiences frostbite of the fingers after prolonged exposure to the cold. Which intervention would the nurse implement first?
Rapid rewarming of the fingers by placing in warm water
The nurse is caring for a child who has frostbite on the legs. On examination, the nurse finds that there are skin blanches at the site of the frostbite. The child does not have any sensation at the site of the injury. Which nursing intervention would be beneficial to the child in this situation?
Rapid rewarming of the injured leg
The nurse is assessing a patient who has a full-thickness wound that has been covered with a hydrocolloid dressing. The nurse finds that the dressing over the wound appears light yellow in color and has a fruity odor. Which is an appropriate nursing intervention?
Reassure the patient that this is normal finding
A child with extensive burns requires debridement. The nurse should anticipate that a priority goal related to this procedure is to
Reduce pain
The nurse is providing long-term care for a child with severe burn injuries. The child has elastic bandages at the site of injury. The primary health care provider has prescribed cetirizine (Zyrtec) for the child. What outcome should the nurse expect in the child after the treatment?
Reduced itching and scarring
The registered nurse (RN) is discussing third-degree burns with a student nurse. Which statement made by the student nurse indicates effective learning?
The sweat glands and hair follicles are destoyed
While assessing a child with a burn injury, the nurse observes that the wound is deep red in color with visible thrombosis and a dry surface. The child reports pinprick sensations at the wound site. The primary health care provider has prescribed autografting for the child. Which stage of burn should the nurse suspect the child to have?
Third-degree
To best assess the child with severe burns for adequate perfusion, the nurse monitors
Urine output
An important consideration for the nurse when changing dressings and applying topical medication to a child's abdomen and leg burns is to
Wash hands and forearms before and after dressing change
An adolescent girl is cooking on a gas stove when her bathrobe catches fire. Her father smothers the flames with a rug and calls an ambulance. She has sustained major burns over much of her body. What is important in her immediate care?
Remove her burned clothing and jewelry
The most immediate threat to life in children with thermal injuries is
Shock
Cellulitis is often caused by
Streptococcus or Staphylococcus organisms
Pathophysiology of Burns
Systemic response involving capillary permeability
A father calls the clinic nurse because his 2-year-old child was bitten by a black widow spider. The nurse should advise the father to
Take the child to emergency department
The primary health care provider prescribes an amputation of a leg to a client with fourth-degree burns. Which characteristic findings should the nurse observe in this client?
The characteristics of the wound observed in a patient with fourth-degree burns include variable colors, such as deep red, white, black, or brown; charring visible in the deepest areas; and limited extremity movement.
The nurse is caring for a child with partial-thickness scald burns of the hands and the face. Which treatment procedure should the nurse expect to be beneficial for the child?
Xenograft transplantation
A child has a minor skin injury due to the accidental handling of mild acids. Which intervention should the nurse provide for this child? Select all that apply.
apply cool water on the wound remove the blisters very carefully cover the burns with a clean cloth
When applying wet compresses or dressings to the skin, the nurse should:
apply the desired solution on cotton gauze or soft cotton cloths such as clean handkerchiefs
The nurse is teaching a class on preventing diaper rash in newborns to a group of new parents. Which statement made by a parent indicates a correct understanding of the teaching?
"I will wash with a mild soap and water and dry thoroughly whenever my infant has a bowel movement."
During the rehabilitative phase of care, pressure dressings are primarily applied to burned areas to
decrease the blood supply to the scar
A mother of a 12-year-old child informs the phone triage nurse that she has just removed a tick from her daughter's scalp and asks whether she needs to be concerned about Rocky Mountain spotted fever. The nurse's best response includes teaching about the clinical manifestations to look for, which include: Select all that apply.
fatique fever petechial rash severe headache
The nurse is caring for a child with partial-thickness scald burns of the hands and the face. Which treatment procedure should the nurse expect to be beneficial for the child?
overweight hypoxemia prolonged infection cotricosteroid therapy
Enteral feedings are ordered for a young child with burns covering 40% of total body surface area. The nurse knows that
paralytic ileus precludes the use of enteral feedings
. Rocky Mountain spotted fever is caused by the bite of a
tick
During a fire accident, the nurse extinguishes the flames and immediately covers the wound of the injured child with a clean cloth. What are the rationales for these nursing interventions?
to reduce pain to prevent hypothermia to prevent contamination
The nurse is teaching a community safety course and demonstrates the proper method to extinguish flames on a person who is on fire. Which statement by the students indicates effective learning?
"Make the person lie down and roll over slowly."
The nurse is giving a health awareness lecture on tick bites at a school. What precautionary measures should the nurse mention? Select all that apply
"Stay away from areas with ticks, such as the woods. Wear light-colored clothing when in tick-infested areas "Perform regular tick checks to the scalp, armpits, and groin
The nurse is taking care of a patient with a burn wound. What should the nurse incorporate into the patient's plan of care when managing the wound?
Ensure that the two burned surfaces are not touching each other
While examining a child with a partial-thickness burn, the nurse finds that the child has a major burn. What is the total body surface area affected in the child?
25%
A patient is admitted with severe burns to the legs. The nurse observes that they are full-thickness burns, and a bone of the left leg is exposed. What does the nurse infer from the depth of injury?
4th degree
One of the first signs of overwhelming sepsis in a child with burn injuries is
Disorientation.
The nurse is caring for a school-age child with a tinea capitis (ringworm) infection. The nurse should expect that therapeutic management for this child includes:
Administering oral griseofulvin
A child is admitted with extensive burns. The nurse notes that there are burns on the child's lips and singed nasal hairs. The nurse should suspect that the child has
An inhalation injury
A child has a small red area and itching on the skin due to a fire ant bite. During assessment, the nurse finds that the child is confused, has respiratory depression, and is in shock. What is the best treatment strategy in this situation?
Antihistamines
A high-protein diet for the child with major burns is ordered to
Avoid protein breakdown
The nurse should understand that Lyme disease is
Caused by a spirochete that enters the skin through a tick bite
The management of a child who has just been stung by a bee or wasp should include the application of
Cool compresses
A child has minor burns on the hands after accidentally handling acids meant for toilet cleaning. What should the nurse do to care for the burns?
Cover the wound with antimicrobial ointment
Hydrotherapy is required to treat a child with extensive partial-thickness burn wounds. Which is the primary purpose of hydrotherapy?
Debride the wounds
Which of the following best describes a full-thickness (third-degree) burn?
Destruction of all layers of skin evident with extension into subcutaneous tissue
